Gastroenterology Coding Alert

Unlisted procedure for anus has got more company than what you think

You're facing a blank wall for your claim if you can't tell the difference between internal and external hemorrhoids. This time around, anatomy could be your biggest ally. Here's a list of misconceptions you should avoid.

1. Hemorroid Location Gives You Nothing

By definition, you can pinpoint an external hemorrhoid if it originates at the lower end of the anal canal near the anus. On the other hand, intermal hemorrhoid is such if it originates at the top (rectal side) of the anal canal. The latter can be much more difficult to diagnose and treat, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPCP, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program.

Wonder what clues you should look for to differentiate one from the other? Turn to the dentate line, which is a mucocutaneous junction about a centimeter above the anal verge, and can be seen separating the anus from the rectum. Internal hemorrhoids occur above the dentate line, and external hemorrhoids occur below the line.

Safe bet: Asking your physician to be clear on the terms she uses on op notes might help. For instance, indicating "internal" or "external" will minimize any potential coding errors.

2. One Hemorroidectomy CPT Covers All

Many coders complain over the lack of specific internal hemorrhoid excision codes, but it doesn't mean your claim should suffer. For the excision of one internal hemorrhoid, some would use the unlisted code 46999 (Unlisted procedure, anus).

However, CPT 2010 has allowed you to be more innovative when coding these procedures. The text note "For excision of internal and/or external hemorrhoid(s), see 46250-46262, 46320" means you can now use 46255 (Hemorrhoidectomy, internal and external, single column/group) for the excision of one internal hemorrhoid (or 46260 [... 2 or more columns/ groups] for excision of multiple internal hemorrhoids).

If the surgeon performed a "transfixion suture excision," where she places a crisscross stitch and ties off the base of the hemorrhoid with the suture (ligation) to control bleeding, you would bill 46945 (Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid column/group)or 46946 (... 2 or more hemorrhoid columns/groups).

Current: You can use 46320 (Excision of thrombosed hemorrhoid, external) to report an excision of a thrombosed  internal hemorrhoid, although the CPT describes an external hemorrhoid procedure. This new rule also comes as an aftermath of the added text note for internal and/or external codes.

3. External Rules Has No Bearing

You should follow external rules for proper code choice, as much as you follow the rules for internal hemorrhoid. Although the new text note for internal and/or external codes might seem to allow 46255 for a single external hemorrhoid, a separate text note following 46250 directs, "for hemorrhoidectomy, external, single column/group, use 46999."

For excision of multiple external hemorrhoids, you should use the most specific code 46250 (Hemorrhoidectomy, external, 2 or more columns/groups), not 46260.